The story of American suicide—more often than not—is a story about an individual who dies by self-inflicted gunshot wound, during their first ever suicide attempt, with a firearm they have owned for years. To put that in more concrete terms, 53 percent of American suicide deaths in 2020 were the result of firearm-related injuries, meaning more than 24,000 Americans died by suicide that year by this one method alone. This is true despite the fact that firearms account for less than 5 percent of annual suicide attempts. In other words, when somebody in America attempts suicide, they almost never use a firearm—and yet—when someone in America dies by suicide, more often than not they used a firearm.
This discrepancy is explained in large part by how uniquely deadly firearms are relative to other methods for suicide. In fact, those who die by suicide using a firearm are more likely than those who die by suicide using any other method to die on their first ever suicide attempt. Intentional overdose is by far the most common method for suicide attempt in the US, but only 2-3 percent of suicide attempts using this method result in death whereas 85-95 percent of all suicide attempts involving a firearm are lethal. The tragedy of this point is highlighted by the fact that 70 percent of those who attempt suicide and survive never attempt again. Second chances matter, but individuals who attempt suicide using a firearm almost never get a second chance.
Intentional overdose is by far the most common method for suicide attempt in the US, but only 2-3 percent of suicide attempts using this method result in death whereas 85-95 percent of all suicide attempts involving a firearm are lethal.
What Are—And Are Not—Risk Factors for Firearm Suicide?
In thinking about the role of firearms in suicide, it is important to carefully consider exactly how the method itself creates risk. Decades of research has shown that firearm access does not cause an individual to become suicidal. Recent research has, however, shown that individuals who purchased firearms since early 2020 are more likely to have experienced suicidal thoughts than are other firearm owners and non-firearm owners, especially if that firearm was the first one they had ever acquired. Still, the general pattern is that firearm owners are no more likely than non-firearm owners to think about suicide. The way that firearms create risk is by providing a lethal path for acting upon existing thoughts. That is, the firearm makes an individual more capable of dying by suicide. When that capability is then paired with an acute desire to die, that is when risk soars.
For some communities, this unfortunate convergence of desire to die and access to firearms is more common. Military service members and veterans, law enforcement officers, individuals living in rural environments, and men—both generally and specifically in middle and older age groups—are disproportionately affected by firearm suicide. Specifically, these groups see a disproportionate percentage of their suicide deaths resulting from firearms rather than any other means. Larger aggregates, such as some states, also see a disproportionate share of suicide deaths result from firearms. I spent the first eight years of my career working in Mississippi where, in 2020, 67.8 percent of all suicide deaths resulted from firearms. I have since moved to New Jersey, where firearm ownership is far lower and where only 26.7 percent of suicide deaths in 2020 resulted from firearms. The fact that a suicide results from a self-inflicted gunshot wound does not make it more or less tragic than any other suicide death, so I do not point this out simply out of a misplaced desire to change how individuals die. Rather, where firearm access is higher and the proportion of suicide deaths resulting from firearms increases, the overall suicide rate goes up. As I noted earlier, firearms are a uniquely lethal method for suicide. When a higher proportion of suicidal individuals in a particular region use this particular method, most suicidal individuals die. The end result is a higher suicide rate.
…the firearm makes an individual more capable of dying by suicide. When that capability is then paired with an acute desire to die, that is when risk soars.
Efforts to Prevent Firearm Suicides
So what can be done about this? There are important lessons to be learned from how we have addressed suicide by other methods in other countries. In each case, success was achieved through means safety—efforts that render a suicide method either less deadly or less readily available. Approaching suicide prevention through the lens of means safety requires us to think about prevention in a way that is different from how many of us have typically done so. The focus in this intervention is not on making individuals less suicidal—instead, the focus is on making the environment less conducive to a suicidal individual acting lethally on their suicidal thoughts. We are not dismissing the importance of making individuals in agony feel better. Instead, we are acknowledging that we often do not know about risk until an individual has already died and, as such, it is beholden upon us to supplement our traditional suicide prevention efforts (e.g., psychotherapy) with efforts to address environmental factors via means safety.
In order to work, means safety requires that the method being addressed be highly lethal and frequently used within a specific geographic space. In the United Kingdom in the mid-20th century, for example, poison gas inhalation via domestic sources (e.g., ovens) was a common method for suicide because the carbon monoxide content in domestic gas was so high. The UK detoxified the domestic gas supply and its suicide rate decreased dramatically, with carbon monoxide suicide deaths almost completely eliminated and suicide rates by other methods holding steady. In Sri Lanka in the early 20th century, a common issue was suicide via pesticide ingestion. When Sri Lanka banned the most lethal brands of pesticide, the overall suicide rate nationwide fell by approximately 50 percent. Perhaps most relevant to the discussion of firearm suicide is the story of the Israeli Defense Force (IDF). The IDF noticed a concerning pattern of young service members killing themselves with their service weapons on weekends and holidays. In response, they shifted policy such that service members had to check their service weapons into an armory when they left for weekends and holidays. Subsequently, the suicide rate among those young service members dropped by 40 percent.
In the US, addressing firearms—a method that is both highly lethal and frequently used—requires creative solutions. In a nation inundated with firearms and where firearm access is a right codified in the Second Amendment, banning firearms is a nonstarter. We also do not currently have any method for rendering a firearm less deadly when used in a suicide attempt. That means that firearms are here to stay and they will maintain their high case fatality rate. Our best option thus may be secure firearm storage. Within the context of suicide prevention, this often means storing firearms unloaded, separate from ammunition, in a locked location (e.g., gun safe) or with a locking device in place (e.g., cable lock). This also often means storing firearms voluntarily and temporarily away from home during times of stress, just as we let someone hold our car keys when we’ve had too much to drink. Unfortunately, secure firearm storage is not the norm. Most surveys show that a meaningful portion of firearm owners store at least one firearm loaded and/or unlocked. Troublingly, some studies—particularly those focused on military populations—have shown that firearm owners with a history of suicidal thoughts are more likely to store their firearms unsafely. Further complicating things is research showing that individuals who died by suicide using a firearm are less likely than those who died by suicide using other methods to have ever engaged with behavioral or mental healthcare providers.
The focus in this intervention is not on making individuals less suicidal—instead, the focus is on making the environment less conducive to a suicidal individual acting lethally on their suicidal thoughts.
If those most vulnerable to firearm suicide are unlikely to tell us about their struggles, to seek professional help, or to even have survived a prior suicide attempt by another method and thus drawn our attention to their need for assistance, then we need to find other ways to reach them without knowing about their suicide risk. Rather than try to find the needle in the haystack with our interventions, we need to implement tools that help both the needle and the hay—we need tools that persuade everyone to store their firearms safely and that shift social norms on this being not only an acceptable behavior, but a desirable one.
There are several tools for promoting secure firearm storage, some with more data supporting them than others.
Lethal Means Counseling
Lethal means counseling—an intervention involving a single conversation focused on promoting secure firearm storage—has been investigated across several settings. My team used a form of lethal means counseling based on motivational interviewing in a project we called Project Safe Guard (PSG). In PSG, we administered lethal means counseling to 232 firearm-owning members of the Mississippi National Guard in a randomized controlled trial and followed up with participants three and six months later. Importantly, we enrolled individuals regardless of whether they had ever experienced suicidal thoughts in an effort to move upstream and ensure that we can prompt behavior change regardless of known (or unknown) risk. We found that those who received lethal means counseling were more likely to adopt secure firearm storage practices (e.g., gun safes, trigger locks) across the follow-up period than were individuals who received the control treatment. We also randomly assigned half of the participants to receive cable locks and found that those who received the locks were far more likely to use locking devices during the follow-up period. Our team is now adapting this intervention to various other communities and to facilitate easier administration and our hope is to broadly disseminate it both within and beyond the military.
Safe Firearm Storage Maps
Another tool being used to address firearm suicide is safe firearm storage maps. First created in Colorado and now present in several states (including New York, New Jersey, Mississippi, Maryland, Washington, and Wisconsin), these tools leverage Google maps and other mapping tools and list firearm retailers and, in some cases, law enforcement agencies in the respective state that are willing to consider temporary storage of privately owned firearms on a case-by-case basis. These tools have not yet been evaluated for effectiveness but represent a potentially invaluable option for facilitating means safety by providing a local avenue for individuals to reduce ready access to firearms during times of stress. Importantly, these tools also provide an option for individuals less inclined to disclose their suicidal thoughts to nonetheless find a path to safety, as they could indicate one of many other reasons for seeking temporary storage away from home (e.g., children are visiting the home or the firearm owner is going out of town).
Public Health Messaging
A third tool that has the opportunity to impact suicide prevention on the population level is public health messaging. Our nation has a long history of using messaging to encourage behavior changes. For instance, “friends don’t let friends drive drunk” and other campaigns played a role in shifting norms on drunk driving. Similar messaging to promote sneezing into our elbows instead of our hands has been used to decrease the spread of communicable illnesses. With secure firearm storage, it is important to consider the message being spread, the identity of the messenger, and the medium through which the message is being delivered. My team and others have done a lot of work in this area. We have a long way to go, but one finding that has repeatedly stood out is that firearm owners across demographic groups have typically listed law enforcement as a particularly compelling voice on this issue. As we move forward, we need to develop messages that leverage the findings from these studies and then disseminate them as broadly as possible. Furthermore, we need to encourage more covert messaging—incorporating secure storage practices into popular media programming without overtly drawing attention to the behavior—as a way to normalize the behavior and model safe practices. This is a sensitive issue that is tied into broader political debates as well as individual identities. Thinking carefully about what we say, how and where we say it, and who is doing the talking will be vital.
Additional Tools to Prevent Firearm Suicide
Other tools exist and more will hopefully come. Lock2Live, for instance, is a free online tool designed for healthcare settings that can assist patients and their families in developing secure storage plans for firearms and medications. Gun shop projects encourage firearm retailers to display and provide information on suicide prevention. Smart gun technology could create obstacles for children and adolescents who might otherwise use their parent’s firearm in a suicide attempt (more than 80 percent of adolescent firearm suicides involve a firearm owned by a family member). Other innovative strategies might assist in our ability to identify, reach, and assist high-risk populations. In the meantime, it is vital that we help our nation understand the scope and nature of this problem, the tools that currently exist, and the urgency of making sure that discussions on suicide prevention keep secure firearm storage at the center of the topic.
ABOUT THE AUTHOR
Michael Anestis, PhD, is a clinical psychologist, the executive director of the New Jersey Gun Violence Research Center, an associate professor in the School of Public Health at Rutgers, and a member of the Regional Gun Violence Research Consortium.